Health care reform shorts: a day observing waste in a medical center

I spent 12 long hours yesterday accompanying a friend who was trying to get urgently needed treatment from a major academic medical facility. It was interesting.

This is not a story about health care denied. My friend has a huge array of medical problems that leave her severely disabled. In consequence she is indigent, dependent on MediCal (Medicaid) and an array of public social service programs for her survival. Stubborn and determined, she works at enlisting and coordinating them all, as much a full time job as any other. She successfully corrals much of the help she needs. At every turn yesterday, she presented her MediCal card and her eligibility for the expensive procedures that a major med center has on offer was never questioned.

Nor is this a story about medical mistreatment or neglect. With rare exceptions, the many people who transported, poked, prodded and diagnosed my friend were polite and professional, though harried. Lying helpless on a gurney while hurting is brutally awful; aides, orderlies, nurses and doctors tried to offer calm and respect. Only one of nearly a dozen examining doctors insulted her dismissively when she questioned what he wanted to do to her body and even he backed off. This was a "good" urban hospital experience.

But what a morass of inefficiencies this day revealed. There must savings that could be squeezed out of the way people get necessary treatment under reform! Some observations:

• My friend tried to approach getting care "right." She somehow wangled an emergency urgent care appointment with a medical resident in the department where her primary care doctor works. She showed up on time. That doctor examined her, consulted with the attending primary care doc -- and they concluded my friend should be sent to the Emergency Room because "she can get tests quickly there." So much for keeping people out of over-burdened ERs. I was deputized to push my friend in a wheel chair across the street to the ER, carrying a sheaf of papers on which the examining doc had recorded her observations.

• When I presented the papers to the ER triage nurse, we had a revealing conversation. She looked at the internal med doctor's notes, commented "that's pretty good handwriting but I still can't read it" and then took my friend through the same narrative of her needs the previous doctor had written up.

• My friend has gotten her care in this system for 15 years. She has a history with them which, when printed out, would probably be the size of a couple of urban phone books (remember those?) Yet every nurse and doc had to ask her the same historical questions and write them down, by hand, on a new form. I can understand repeatedly asking about drug allergies -- that might be life saving. But this woman's "chart" is so unwieldy and the medical people so rushed, as far as I could tell they simply didn't try to read it. From the patient's standpoint, the inquiries start out helpful, but when asked over and over, come to feel abusive.

• This is not a crumbling public charity hospital (see pic above). But nurses and orderlies seemed to spend much of their working lives running from place to place looking for what must be fairly common supplies: for example more plastic tape or a portable commode.

• Each phase of the diagnostic process would run into a moment when the resident doctor who'd just seen my friend would retreat to a hallway to try to find out who the appropriate specialist to call in might be. Because this is a teaching hospital, any sort of specialist needed seemed be available somewhere in the complex -- but the ER docs spent a lot of their day trying to figure out who might be on duty and where they should call.

• When the ER finally decided to admit my friend to the hospital proper, then the search for an available bed began. Several of her hours taking up an ER cubicle with all its associated high tech facilities passed while doctors and clerks tried to coordinate with the main hospital. Meanwhile, more patients were crowding the ER waiting room, hoping to get into the cubicles.

These medical people were obviously working diligently to provide the best care they could in difficult circumstances (though by no means the most difficult). And people were getting cared for.

But I do hope the reform we seem to be getting can lead to universal adoption of electronic health records. And there must be some way to achieve better coordination among the parts of the medical non-system.